Systemic Lupus Erythematosusand Antiphospholipid Syndrome by qga16183

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polymorphisms between the RP patients and controls were analyzed by chi-square           Background: To identify Lupus patients’ knowledge on their disease manifestation
analysis with correction for multiple comparisons. A value of p > 0.05 was               and medication targeting through improvement of knowledge, compliance with
considered statistically significant.                                                    treatment.
Results: All the genotypes tested were in Hardy-Weinberg equilibrium. No                 Methods: Patients from 2 different DGH in Essex were asked the following
significant difference was found in genotype, allele frequency or haplotypes for         questions: 1) ‘‘Do you know that the disease can affect many systems of your
any of the investigated polymorphisms in EDN1, EDNRA and EDNRB between the               body?’’ Potential answers ‘‘yes’’ or ‘‘no’’.
PRP, SRP or RP group as a whole and control subjects.                                        ‘‘From the systems listed below tick the ones the disease can affect’’.
Conclusions: These results do not support an association of genetic variations in        The systems listed and the order were: skin, hair, lungs, heart, joints/muscles,
the members of the endothelin family with Raynaud’s phenomenon. Nevertheless,            blood, blood vessels, kidneys, neurology (headache, migraines, depression, mental
the endothelin system may play an important role in the pathogenesis of the              illness), fever, psychiatry, miscarriages, fatigue, swollen glands, all the above.
abnormal vasoespastic response that characterizes RP by different mechanisms,                The question on the medication was: ‘‘do you know that drugs used are
unrelated to genetic variations studied.                                                 suppressing the system that fights the infections?’’ A list of current and past
Disclosure: The authors have declared no conflicts of interest.                          medication requested. A final question asking whether they have ever been part of
                                                                                         any Lupus group was asked.
                                                                                         Results: A total of 41 patients reported on the questions. They were 3 males and
                                                                                         38 females with a mean age of 46 (sd þ 13.7).) The mean age at diagnosis was 40
            Systemic Lupus Erythematosus and                                             (þ 13.3 (12-68), disease duration 9 years (þ 9.7) from the time of symptoms onset,
                Antiphospholipid Syndrome                                                and delay in diagnosis of 1 years (þ 2.9). Patients were of diverse ethnic
                                                                                         background (16 white/Caucasians, 19 Asians, 4 Africans/Afro-Caribbean’s and
                                                                                         2 stated British but not ethnic background).
                                                                                             Knowledge on systems that can be affected by Lupus:
308. DIRECT COMPARISION OF PRE-ATHEROSCLEROTIC                                               Most patients know (15/41; (36.5%) that all symptoms from systems mentioned,




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VASCULAR SURROGATE MEASURES IN PATIENTS WITH SYSTEMIC                                    can be affected; 4/41 (9.7%) did not know that many bodily systems can be
LUPUS ERYTHEMATOSUS AND RHEUMATOID ARTHRITIS                                             affected; 22/41 (53.6%) reported between 1 and 13 symptoms from systems listed
Lubna Aslam1, Stephen Oakley1, David D’Cruz1, Phil Chowienczyk2 and                      that can be affected.
Kirkham Bruce1                                                                               Knowledge on Medication: Most patients (34/41; 82,9%) know that drugs
1                                                                                        used are suppressing the immune system, 5 patients (12.1%) did not know and
  Rheumatology Department, Guy’s &St.Thomas’ Hospital, London,
                                                                                         2 did not state.
United Kingdom and 2Pharmacology Department, Guy’s & St.Thomas’ Hospital,
                                                                                             There were 2 questions regarding medication: These questions were assessing
London, United Kingdom
                                                                                         current (time of questionnaire administration) as well as past medication.
Background: Surrogate markers for subclinical atherosclerosis have been                      At the time of questionnaire completion 11 patients were on no medication and
shown to be abnormal in patients with systemic lupus erythematosus (SLE) and             1 did not state. A total of 18 patients were on hydroxychloroquine (HCQ) either
rheumatoid arthritis(RA). This study compared the magnitude of surrogate pre-            alone (10/41; 24.3%) or in combination with other immuno suppressants including
atherosclerotic abnormalities in age and sex-matched with SLE and RA patients.           steroids. On immuno suppression alone were 6/41 patients (14.6%).
Methods: 21 patients with SLE and RA were enrolled into the study. Both groups               With regards to past medication, 12 patients were on no medication, 9 solely on
had no excess traditional cardiovascular risk factors and underwent assessment of        anti-malarials, and 21 on immuno suppressants (including steroids).
vascular endothelial function(flow mediated dilatation, FMD) and arterial stiffness          Finally only 3 out of 41 patients (7.3%) have ever joint a Lupus group, 37/41
(carotid-femoral pulse wave velocity, PWV). Demographic, laboratory, and risk            (90.2%) never joint a group and 1 did not state.
factors data were collected on the day of ultrasound examination. FMD was                Conclusions: Overall patients with Lupus have an acceptable level of knowledge
measured using B-Mode dopplers and PWV waveforms were collected from the right           on their disease despite the fact that only a small minority is part of a Lupus group.
carotid and femoral arteries by Doppler probes.Disease activity was measured in          Disclosure: The authors have declared no conflicts of interest.
both groups: British Isles Lupus Assessment Group(BILAG) in SLE patients and
disease activity score 28 (DAS 28) in RA group. SLE disease damage was assessed
by Systemic Lupus International Collaborating Clinics(SLICC). We were unable to          310. THERAPEUTIC EFFICACY OF INFLIXIMAB IN A PATIENT WITH
obtain accurate data on disease duration in some SLE patients, as referral letters did   ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS
not provide sufficient information as to when the diagnosis was made.
                                                                                         Sukhbir S. Uppal
Results: The mean age of the women in the SLE group was 48.3 (SDþ/-14.9)
                                                                                         Medicine, Kuwait University, Kuwait, Kuwait
versus 47.1 (SDþ/-14.5) in the RA group. Patients with RA had a significantly
increased inflammatory burden compared with patients of SLE(mean ESR:31.3 vs             Background: Systemic lupus erythematosus (SLE) looms as a serious unsolved
12.5 P ¼ 0.003, mean high sensitivity C-reactive protein, hs CRP: 17.4 in RA vs          problem in rheumatology. Presently, long-term administration of glucocorticoids
1.32 in SLE patients P < 0.001). RA patients had a very high DAS28 (mean-5.5) in         continues to be the sheet anchor for control of disease activity in SLE(1). The side
contrast to lupus patients who had very mild disease at the time of recruitment both     effects and toxicities of glucocorticoids are well known, and furthermore, they are
in terms of activity and damage. There was no difference in PWV (8.32% vs 8.66%)         only partially successful in controlling lupus activity (1). Besides the administration
between SLE and RA patients. Similarly the FMD values did not differ between the         of glucocorticoids, there are limited therapeutic options such as hydroxychlor-
2 groups (6.12% and 6.42%).                                                              oquine, azathioprine, methotrexate, mycophenolate mofetil, and recently, ritux-
Conclusions: This is the first study directly measuring vascular risk factors in         imab. Therefore, new treatments for SLE are urgently needed. Objectives: To
patients with SLE and RA in the same laboratory with no evidence of cardiovascular       assess the safety and efficacy of infliximab, a chimeric monoclonal antibody
disease.Our data shows similar values for the surrogate measures of vascular             directed against TNF, given to a patient with active SLE, since disease activity in
function (FMD), and structure (PWV) in SLE and RA, despite higher inflammatory           SLE correlates well with increased serum levels and activity of the cytokine tumor
burden in patients with RA. Epidemiological data suggests a higher incidence of          necrosis factor alpha (TNF-)(2;3).
cardiovascular adverse events with lower age of onset in SLE patients even in            Methods: This 25-year-old unmarried Kuwaiti woman, was diagnosed to have
those with mild disease compared to RA. Our data suggest that non-vascular               active SLE on the basis of diffuse alopecia, Raynaud’s phenomenon, and typical
components (e.g.prothrombotic factors, anti-endothelial antibodies) play an              SLE serology. Inspite of treatment with hydroxychloroquine (HCQ), methotrexate
important additive role in SLE.                                                          and glucocorticoids, she presented on multiple occasions with significant disabling
Disclosure: The authors have declared no conflicts of interest.                          non-erosive RF-negative polyarthritis, pleurisy, pericardial effusion and Raynaud’s
                                                                                         phenomenon associated with active SLE serology requiring methylprednisolone
                                                                                         pulse therapy each time. Even when methotrexate was substituted by azathioprine
Variables              SLE                     RA                p          Rank sum
                                                                                         200 mg/day as a steroid sparing agent, the patient failed to remit.
                                                                                             At this stage, she was recruited into an open label study on the safety
               Mean           SD       Mean          SD
                                                                                         and efficacy of infliximab in patients with active lupus. She was commenced in
Age            48.3          14.9      47.1         14.5        0.806          0.823     May 2005 on a protocol of 400 mg (3 mg/kg body weight) infliximab infusions at 0, 2,
ESR            12.5           2.3      31.3          5.4        0.003          0.016
CRP             1.32          0.29     17.4          3.7       <0.001         <0.001
                                                                                         6, 14, and 22 weeks. The treatment she was already receiving was initially
BILAG           1             N/A       N/A          N/A        N/A            N/A       continued.
SLICC           0.0           0.0       N/A          N/A        N/A            N/A       Results: One month after starting infliximab, the patient reported a sense of well
DAS28           N/A           N/A       5.5          1.3        N/A            N/A       being and was totally symptom-free. Lupus serology showed marked improvement.
FMD             6.12          0.66      6.42         0.46       0.915          0.561     Health status measures (SF-36 and VAS-fatigue) and disease activity measures
PWV             8.32          0.47      8.66         0.33       0.670          0.330     (patient’s global assessment of disease activity and SLEDAI) also showed marked
                                                                                         improvement. Meanwhile glucocorticoids were tapered and then completely
309. LUPUS PATIENTS’ PERSPECTIVE ON THEIR                                                stopped. Azathioprine was also stopped and only HCQ 400 mg/day was
DISEASES.(ASSESSMENT OF THE KNOWLEDGE OF LUPUS                                           continued. The patient continues to do well only at one year after her last infliximab
PATIENTS ON DISEASE AND MEDICATION AIMING TO IMPROVE                                     infusion.
COMPLIANCE WITH TREATMENT)                                                               Conclusions: Our case report indicates that anti-TNF alpha therapy may
                                                                                         constitute an interesting candidate approach for treating SLE, but large clinical
Euthalia Roussou1, Caroline Iacovou1, Khalid Ahmed2 and Anita Weerakoon2                 trials will be required to answer whether TNF alpha blockade fulfils this hope with an
1
 Rheumatology & Rehabilitation, King George Hospital, Ilford, United Kingdom             acceptable safety profile.
and 2Rheumatology, Princess Alexandra Hospital, Harlow, United Kingdom                   Disclosure: The author has declared no conflicts of interest.
ii92    Thursday 24 April 2008, 08.30–10.00                                                                                                            Poster Viewing ll

311. A PILOT STUDY OF THE 24-HOUR VARIABILITY OF BLOOD                                   steroid use. These patients are likely to be at low risk of cardiovascular disease
PRESSURE AMONG PATIENTS WITH SYSTEMIC LUPUS                                              provided disease activity is controlled and traditional cardiovascular risk factors are
ERYTHEMATOSUS                                                                            modified or absent.
                                                                                         Disclosure: R.D. has received financial support from Aspreva Pharmaceuticals
Charlotte Carter and Karen Walker-Bone                                                   and Roche supplied study medication and placebo for this study. J.D. has received
Rheumatology, Brighton & Sussex Medical School, Brighton, United Kingdom                 financial support from Aspreva for a technician. All other authors have declared no
Background: Systemic Lupus Erythematosus (SLE) is known to be associated                 conflicts of interest.
with increased risk (10-15 times) of cardiovascular mortality and morbidity. It has
been demonstrated that conventional ‘Framingham’ risk factors e.g. hypertension,         Baseline Characteristics
hyperlipidaemia, and diabetes explain some but not all of the excess risk.
                                                                                                                                       A (n ¼ 34)                  B (n ¼ 36)
Hypertension has been traditionally assessed by clinic readings but several studies
have shown poor correlation between clinic BP and 24-hour average BP, largely            Age (yr)                                      42.85 Æ 8.37                43.22 Æ 10.14
because of ‘white coat hypertension’ whereby BP decreases when measured away             Disease duration (yr)                         10.11 Æ 7.22                8.26 Æ 10.14
                                                                                         HCQ (%)                                       97%                         94%
from the clinical environment. In non-SLE patients, 24 hour ambulatory monitoring        Duration HCQ (yr)                             7 Æ 6.25                    5 Æ 3.44
is a more accurate predictor of target organ damage and cardiovascular risk.             Pred. (%)                                     32%                         33%
To date there have been no published data on the 24 hour variability of blood            Duration pred. (yr)                           13.4 Æ 5.44                 6 Æ 9.29
pressure among patient with SLE and its role in evaluating cardiovascular risk.          Caucasian (%)                                 76%                         67%
I was therefore keen to assess this risk during my undergraduate training by             Ex-smoker (%)                                 32%                         33%
undertaking a small pilot study.                                                         Body Mass Index                               27.19 Æ 6.94                27.62 Æ 5.81
Methods: Subjects with SLE (as defined by revised 1982 ACR criteria) were                Systolic BP (mmHg)                            122 Æ 16.88                 120 Æ 15.26
                                                                                         Diastolic BP (mmHG)                           82 Æ 11.82                  80 Æ 10.06
identified from the database of the Rheumatology Department of a teaching                Total Fasting cholesterol (mmol/l)            4.55 Æ 0.63                 4.62 Æ 1.36
hospital. All participants (cases and controls) completed a validated questionnaire




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which collected information about cardiovascular risk factors. Additional information    Values; mean Æ sd.
about the SLE subjects was extracted from their hospital notes, including: all
clinic BP readings, diagnostic information and measures of cardiovascular risk and
disease activity.                                                                        313. DIABETES MELLITUS COMPLICATING SYSTEMIC LUPUS
Results: In total, 11 females with SLE and 14 age-matched controls were recruited.       ERYTHEMATOSUS - ANALYSIS OF THE UCL LUPUS COHORT AND
The SLE cases had higher mean BMI and were less physically active than their             REVIEW OF THE LITERATURE
controls. Table 1 summarises some of the different parameters of blood pressure
for the cases, as compared with controls. No significant differences were found for      Sara Cortes1, Chambers Sharon2, Ana Jeronimo3 and David Isenberg2
                                                                                         1
any parameter. Additionally, our results suggested that clinic BP measurements             Portuguese Institute of Rheumatology, R.Beneficiencia, 7, 1050-034, Lisbon,
were highly significantly correlated with 24 hour parameters.                            Portugal, 2Centre for Rheumatology, Dept of Medicine, University College
Conclusions: Although SLE patients had higher BMI and were less physically               London, London, United Kingdom and 3Rheumatology, Pedro Hispano Hospital,
active, cases and controls showed remarkably little difference in all parameters of      Matosinhos, Portugal
blood pressure over 24 hours. Clinic BP readings are, in this small population,
highly significantly correlated with 24 hour parameters. These results will be of        Background: Systemic Lupus Erythematosus (SLE) often coexists with other
relevance to rheumatologists and CVS physicians, as well as general physicians           diseases. Diabetes mellitus (DM) is an example and patients with overlap SLE-DM
and general practitioners. A direct benefit for the participants was the opportunity     can present with clinical features common to both disorders. We have identified
for their BP to be assessed over 24 hours. As a final year student it gave me            patients overlap SLE-DM in a large SLE cohort focusing on the clinical features
opportunity to use, and interpret 24 hour ambulatory monitoring as well appreciate       common to both diseases that these patients can develop, and on the challenges
the complexities of multi-system rheumatological diseases.                               of managing such complications.
Disclosure: The authors have declared no conflicts of interest.                          Methods: A detailed review of the patients notes (n ¼ 485) was performed. At every
                                                                                         outpatient appointment the patients urine was tested for glucose, protein and blood.
                                                                                         Patients with persistent glycosuria were investigated with fasting blood glucose and
Comparison of BP parameters                                                              a glucose tolerance test to help make the diagnosis of DM. Particular note was
                                      Cases              Controls              p-value   made of those patients whose symptoms could be due to SLE, DM or both.
Mean systolic BP                       125.9               127.9                0.466
                                                                                         Results: 9 patients with DM were identified. 3 had type 1 DM, 4 had type 2 DM and
Minimum night diastolic BP              57.0                56.1                0.873    2 were considered to have steroid-induced DM. Among these patients, 3 had renal
                                                                                         involvement (2 with WHO class IV lupus nephritis); 2 had peripheral neuropathy
                                                                                         (1 had a mixed sensory and motor neuropathy, 1 had a sensory peripheral
                                                                                         neuropathy); 2 patients had retinopathy and cataracts and 1 had angina.
                                                                                         Conclusions: The combination of SLE and DM is uncommon but the predisposi-
312. THE MISSILE STUDY: A RANDOMISED CONTROLLED                                          tion to renal, peripheral neuropathy and retinal disease means that great care must
TRIAL OF MYCOPHENOLATE MOFETIL VERSUS PLACEBO ON                                         be taken when deciding which clinical feature is due to which disease, since active
SURROGATE MARKERS OF ATHEROSCLEROSIS IN SYSTEMIC                                         SLE requires additional immunosuppression whereas DM requires optimization
LUPUS ERYTHEMATOSUS                                                                      of the metabolic control. Interestingly, although in theory patients with SLE and
                                                                                         DM are in double-jeopardy of developing atherosclerosis, to date, only one of our
R. Davies1, S. Sangle1, G. Hughes1, J. Deanfield2 and D. D’Cruz1                         overlap patients has developed angina.
1
  Lupus Research Unit, St Thomas’ Hospital, London, United Kingdom and                   Disclosure: The authors have declared no conflicts of interest.
2
  Vascular Physiology, GOSH, London, United Kingdom
Background: Systemic lupus erythematosus (SLE) is thought to be an
independent risk factor for atherosclerosis. Endothelial dysfunction is the earliest     314. THE INFLAMMATORY EFFECTS OF MINOCYCLINE ARE
marker of atherosclerosis and is measured by flow mediated dilation (FMD) of the         ALTERED BY OXIDATION
brachial artery. Our hypothesis: Mycophenolate mofetil (MMF) is superior to              Chetna Dharmapalaiah2, Nick Amos2, Jeremy P. Camilleri2 and Stefan Siebert1
placebo in suppressing inflammation and improving endothelial function in SLE            1
                                                                                           Medicine, Swansea University, Swansea, United Kingdom and 2Rheumatology,
as measured by FMD.                                                                      University Hospital of Wales, Cardiff, United Kingdom
Methods: A prospective, double-blind, randomised, placebo-controlled trial
evaluating MMF on surrogate markers of atherosclerosis in mild SLE. 70 females           Background: Minocycline is a semi-synthetic tetracycline which is most commonly
fulfilling ACR criteria were recruited and allocated by minimisation to either placebo   used for the treatment of acne vulgaris and rosacea. As well as its use as a
or MMF 1gm bd for 8 weeks. The primary end point was change in FMD assessed              bacteriostatic antibiotic, minocycline has also been shown to have both anti-
on an intention to treat basis. Other inclusion criteria were mild and stable disease,   inflammatory and anti-apoptotic activity. Long term treatment with minocycline can
18-60 years, on hydroxychloroquine and/or 15mgs prednisolone od. Exclusions              lead to the development of a lupus-like syndrome (minocycline-induced lupus, MIL)
were smokers, other immunosuppressants, ischaemic heart, cerebrovascular or              which is characterised by systemic inflammation, fever and arthralgia. We have
end stage renal disease. A minimum of 30 subjects per group were required                previously shown that re-challenging these patients with oral minocycline results
to detect a change in FMD with a power of 90% at a 5% significance level. The            in rapid recurrence of the systemic inflammatory response with release of the
patients were allocated to Group A and Group B; the study remains blinded due to         pro-inflammatory cytokines IL-6 and TNF. Minocycline appears capable of both
ongoing analysis.                                                                        pro- and anti-inflammatory activity in different settings, although the mechanisms
Results: Seventy patients were recruited and 63 completed the study. Seven failed        for these effects are unknown. Rubin has proposed that oxidative metabolites of
to complete: 4 were lost to follow up and one each was withdrawn with breast             certain drugs triggers drug induced lupus and we therefore wished to examine
cancer, a urinary tract infection and leucopenia. The FMD for both groups was            if oxidation of minocycline alters it’s biological activity.
within the normal range at baseline and failed to change significantly in either group   Methods: Minocycline is oxidised spontaneously in slightly alkaline solutions which
post treatment. Group A mean FMD% pre-treatment was 7.61 Æ 3.48 and post-                was achieved by incubation in serum free medium at 37oC. The effect of this
treatment 7.29 Æ 3.21 (p ¼ 0.6) and Group B mean FMD% pre-treatment was                  oxidised minocycline and unoxidised minocycline on spontaneous or inducible
8.36 Æ 4.11 and post-treatment 8.98 Æ 5.47 (p ¼ 0.27).                                   cytokine production was compared in whole blood. Cell viability and IL-6
Conclusions: In SLE patients with mild, stable disease on hydroxychloroquine,            spontaneous secretion were assayed following incubation with drug (0 to 100mM)
endothelial function was well preserved despite moderate disease duration and            for 24 hours. Inducible IL-6 secretion was measured following incubation with LPS.
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Results: After 24 hours incubation with minocycline, no statistically significant        of medications were the main reasons for poor adherence, but some
effect on cell viability was observed with doses up to 100 mM, although oxidised         patients chose not to take their medications because of side effects, perceived
minocycline resulted in a slight decrease (16% p < 0.01) in cell viability at 24 hrs     mild severity of their disease and/or a preference to take drugs only when
at 100 mM. No statistical difference was seen in spontaneous IL-6 production             symptomatic.
with either preparation.                                                                     Patients used herbal medicines to counteract side effects of Western medicines,
    Pre-incubation with minocycline resulted in a dose-dependent inhibition of           to ‘purge the blood’ and to manage lupus symptoms when they had no medications.
LPS-induced IL-6 production, significant inhibition occurring at 50 mM                   Religious beliefs were used as a coping strategy. Traditional use of herbal
(35%, p < 0.05) and 100 mM (76%, p < 0.01). This inhibition of LPS-induced IL-6          medicines is common particularly in patients from rural Jamaica, and may explain
was lost with oxidised minocycline with no IL6 inhibition at 100 mM of oxidised drug.    the observed use of herbal medicines in those who have emigrated to developed
In contrast, significantly enhanced LPS-induced IL6 production was observed at           countries.
lower concentrations of oxidised minocycline, with maximum IL6 production                Conclusions: Socio-economic constraints and poor drug availability are particu-
occurring at 6.25mM of oxidised drug (approximately 3-fold increase in IL-6).            larly important influences on poor adherence in Jamaican patients with SLE.
Conclusions: Neither form of minocycline induced spontaneous IL6 production              Religious beliefs and use of herbal remedies do not seem to affect adherence
in vitro. However, unoxidised minocycline had an anti-inflammatory effect,               adversely but are used when drugs cannot be obtained.
as observed by its inhibition of LPS induced IL-6, that was lost on oxidation.           Disclosure: The authors have declared no conflicts of interest.
In contrast, oxidised minocycline, but not unoxidised minocycline had a ‘‘pro-
inflammatory’’ effect at lower concentrations. Therefore, the in vivo biological
activity of minocycline may be dependent upon its oxidation status and could play a
role in the development of MIL                                                           317. B CELL CYTOKINES AS NOVEL BIOMARKERS TO PREDICT
Disclosure: The authors have declared no conflicts of interest.                          RELAPSE AND GUIDE RITUXIMAB RE-TREATMENT IN SYSTEMIC
                                                                                         LUPUS ERYTHEMATOSUS (SLE) AND ANCA ASSOCIATED
                                                                                         VASCULITIS (AAV)




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315. NITRIC OXIDE AND ITS FREE RADICAL DERIVATIVES IN
PRIMARY ANTIPHOSPHOLIPID SYNDROME                                                        Amit J. Shah, Rachel D. Jones, David Jayne, Ken G. Smith and
               1                  2                    3                   4
                                                                                         Menna R. Clatworthy
Paul R. Ames , Joana Batuca , Jose’ Delgado Alves , Antonio Ciampa ,                     Medicine, University Of Cambridge, Cambridge, United Kingdom
Scenna Giovanna5, Iolanda Antinolfi5 and Felicetto Ferrara5
1
  Immunoclot Ltd, Leeds, United Kingdom, 2Pharmacology, Faculty of Medical               Background: Rituximab an anti CD20 B cell depleting monoclonal antibody is a
Sciences, Lisbon, Portugal, 3Autimmune Disease Unit, Curry Cabral Hospita,               potential new therapy for SLE and AAV. Following a single rituximab course the
Lisbon, Portugal, 4Haemostasis Unit, Moscati Hospital, Avellino, Italy and               duration of B cell depletion is variable (10 months median, 2 - 30 months range).
5
  Haemostasis Unit, Cardarelli Hospital, Nalpes, Italy                                   Remission duration following rituximab treatment is also highly variable (13 months
                                                                                         median, 6 - 49 months range). At present the relationship between B cell return and
Background: Nitric oxide (NOx) is the prototypical vasodilator agent whose               relapse is not sufficiently accurate to guide rituximab re-treatment timing on blood B
biological activity is lost in early atherosclerosis. In the presence of free radicals   cell levels alone. This variability in time to relapse in relation to B cell return may
NOx gives rise to peroxynitrite (ONOO-) that in turn can attack tyrosine residues        be influenced by B cell stimulatory cytokines. The B cell stimulatory cytokine, B cell
in proteins. We explored the behaviour of NOx, ONOO- and nitrotyrosine (NT) in           activation factor of the tumour necrosis family (BAFF) is elevated in patients with
PAPS.                                                                                    SLE and AAV. However, the role of BAFF as a relapse predictor in rituximab
Methods: NOx (NO2-, NO3-, Greiss reagent, spectrophotometry), ONOO- as total             treated SLE and AAV patients has not been investigated.
antioxidant capacity of plasma (TAC) by ONOO- quenching (spectrophotometry),             Methods: 6 patients with SLE and 6 patients with AAV received a course of therapy
NT and IgG anticardiolipin (aCL) by Elisa were assessed in consecutive PAPS              with rituximab along with a single dose of intravenous cyclophosphamide. They
patients with vascular events (A n ¼ 14, V ¼ 26), thrombotic controls (A n¼11,           were followed longitudinally with serum samples being collected until symptoms
V¼25) with inherited thrombophilia (IT) and normal controls.                             relapsed. Serum levels of BAFF were measured at four B cell related time-points:
Results: PAPS patients had lower NO2- than other groups, but higher TAC and              (a) baseline (pre-rituximab) (b) B cell depletion (<0.02 x 109 cells/litre) (c) B cell
equal NT. In PAPS mean NO3- was lower in patients with a history of arterial than        return (>0.02 x 109 cells/litre) (d) relapse. Serum levels of BAFF were measured by
venous thrombosis (11.41 Æ 7.6 vs 18.43 Æ 11.06, p¼0.03) and IgG aCL inversely           enzyme-linked immunosorbent assays.
correlated with NO3- (r¼ -0.34, p¼0.03).                                                 Results: BAFF levels increased in patients with SLE from 15.16ng/ml at B cell
Conclusions: These data argue against the formation of reactive nitrogen species         return to 18.9 ng/ml at relapse. However with only 6 SLE patients this increase was
in PAPS, but highlight the decrease of NOx as an important pathogenetic factor           not significant. BAFF levels increased in patients with AAV from 24.87ng/ml at B
particularly in arterial disease.                                                        cell return to 40.57ng/ml at relapse. Similar to the SLE data with a sum total of
Disclosure: The authors have declared no conflicts of interest.                          6 AAV patients this increase was not significant. In both the SLE and AAV patient
                                                                                         groups there appear to be subsets of patients with either low (2 - 20 ng/ml) or high
                                                                                         (40- 80 ng/ml) BAFF levels at baseline. Preliminary studies with microarray assays
                        PAPS                IT               CTR               p value   looking at BAFF mRNA expression shows that patients can be categorised into
No                       40                 36                36                         high or low BAFF producers at baseline based on their monocyte counts, one of the
F/M                    23/17               20/16            17/10                        predominant sources of BAFF.
Age (years)            42 Æ 9             42 Æ 11           45 Æ 9                       Conclusions: The levels of the B cell cytokine BAFF do increase in patients with
NO2 (umol/L)          12 Æ 7.3           16 Æ 9.6          26 Æ 12.4           <0.0001   SLE and AAV between B cell return and relapse. However, further study is needed
NO3 (umol/L)          16 Æ 6.3           16 Æ 6.3          14 Æ 8.6              ns
TAC (mmol/L)          10 Æ 12.5          7.3 Æ 6.4         8.4 Æ 7.6           <0.0001
                                                                                         with larger cohort numbers to elucidate significant changes in BAFF levels between
NT (nM)               12 Æ 14.2          16 Æ 12.6         18.2 Æ 14             ns      B cell return and relapse. This can then establish whether BAFF levels can be
                                                                                         used to predict relapse once B cells have returned thereby guiding rituximab
                                                                                         re-treatment. Correlating the mRNA expression studies to each patient’s baseline
                                                                                         levels of BAFF may enable better interpretation of the BAFF levels at various B cell
316. FACTORS INFLUENCING ADHERENCE TO MEDICATIONS IN A                                   related time points.
GROUP OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS                                      Disclosure: The authors have declared no conflicts of interest.
(SLE) IN JAMAICA
Sharon A. Chambers3, Rosalind Raine1, Anisur Rahman3, Karel De Ceulaer2,
Karlene Hagley2 and David Isenberg3                                                      318. LOW GRADE INFLAMMATION AND IN VIVO IMMUNE
1
  Department of Epidemiology and Public Health, University College London,               ACTIVATION IN PRIMARY ANTIPHOSPHOLIPID SYNDROME
London, United Kingdom, 2Department of Medicine, University of the West
Indies, Kingston, Jamaica and 3Department of Medicine, University College                Paul R. Ames1, Antonio Ciampa2, Eiji Matsuura3, Luis Lopez4,
London, London, United Kingdom                                                           Giovanna Scenna5, Iolanda Antinolfi5, Luigi Iannaccone5 and Felicetto Ferrara5
                                                                                         1
                                                                                           Immunoclot Ltd, Leeds, United Kingdom, 2Haemostasis Unit, Moscati Hospital,
Background: Poor adherence to medications is suspected to contribute to the              Avellino, Italy, 3Cell Chemistry, Okayama University, Okayama, Japan, 4Corgenix
adverse outcomes observed in Afro-Caribbeans with SLE in the UK. 52% of                  Ltd, Broomfield, CO and 5Haemostasis Unit, Cardarelli Hospital, Naples, Italy
Caribbean nationals in the UK are Jamaicans. Our aim was to examine the factors
influencing adherence to medications in a group of patients with SLE in Jamaica.         Background: The issue of inflammation and in vivo immune activation in
Methods: We undertook a qualitative study using a screening questionnaire and            thrombotic primary antiphospholipid syndrome (PAPS) has been little addressed.
semi-structured one hour long interviews in the rheumatology clinic at the University    HIgh sensitivity C reactive protein (CRP), serum amyloid A (SAA), soluble CD14
Hospital of the West Indies, Kingston, Jamaica. 75 patients with SLE participated        (sCD14) and neopterin (NPT) are sensitive markers of inflammation and immune
including 20 interviewees who had had SLE for at least one year. Those                   activation in vivo.
interviewees were all born in Jamaica, administered their own tablets and were           Methods: SAA, CRP, sCD14, NPT, IgG anticardiolipin antibodies (aCL) and IgG
taking at least one immunosuppressive. The main outcome measures were:                   anti beta-2-glycoprotein-I (a2GPI) were measured by Elisa in consecutive
1) Level of self-reported adherence in a sample of the cohort 2) Interviewees’           thrombotic patients with PAPS, thrombotic controls with inherited thrombophilia
explanation of the reasons for taking or not taking drugs as prescribed by their         (IT) and normal controls. Demographics and results by group are shown in table.
physician.                                                                               Results: Neopterin was higher in PAPS patients with a history of arterial
Results: 56% of the 75 study participants (73F 2 M) reported taking                      thrombosis (p ¼ 0.02). Within PAPS IgG aCL correlated to neopterin (p ¼ 0.01)
their medications more than 85% of the time. High cost and poor availability             and IgG a2GPI to sCD14 (p ¼ 0.001).
ii94   Thursday 24 April 2008, 08.30–10.00                                                                                                               Poster Viewing ll

Conclusions: PAPS is characterised by low grade inflammation and immune                Methods: Children (diagnosed <17 years) with JSLE (n ¼ 6), Juvenile Idiopathic
activation in vivo that might bear relevance to atherosclerosis.                       Arthritis (JIA) (inflammatory controls; n ¼ 6) and Controls (children with no
Disclosure: The authors have declared no conflicts of interest.                        inflammatory condition/infection) were investigated. Adult SLE patients (n ¼ 6)
                                                                                       were recruited from Aintree University Hospital. Heparinised whole blood and
                                                                                       serum samples were collected. Neutrophils were isolated and incubated either with
                        PAPS               IT               CTR             p-value    no serum, JSLE, SLE, JIA or Control serum. Apoptosis (annexin V) and necrosis
No                        42               39                41                        (PI) were examined by flow cytometry over a predefined time course and confirmed
F/M                     25/17             23/16             20/21                      by morphological examination
Age (yrs)               42 Æ 9           44 Æ 12            46 Æ 8                     Results: JSLE and SLE neutrophils underwent increased apoptosis as compared
CRP (mg/dl)           0.6 Æ 0.8         0.2 Æ 0.2        0.15 Æ 0.17         0.0009    to JIA (p < 0.05) and control neutrophils over time(see table). Incubation of
SAA (ng/ml)           54.3 Æ 60        29.07 Æ 44        7.6 Æ 19.4          0.001     neutrophils with JSLE & SLE serum significantly (p < 0.05) increased apoptosis in
NPT (nmol/ml)          14 Æ 9.4         7.4 Æ 3.5         6.1 Æ 2.1         <0.0001
sCD14 (mg/ml)         1.6 Æ 0.56        1.4 Æ 0.3         1.4 Æ 0.2          0.03
                                                                                       all groups compared to control serum (see table)
                                                                                       Conclusions: We have shown altered (increased) apoptosis in JSLE and SLE
                                                                                       by two possible mechanisms, relating to the neutrophils themselves and
                                                                                       serum. We plan to extend this work by quantifying serum factors
319. EXPOSURE OF PODOCYTES TO IMMUNOGLOBULIN G FROM                                    influencing apoptosis and by assessing phagocytic clearance of apoptotic
PATIENTS WITH LUPUS NEPHRITIS CAUSES                                                   neutrophils in JSLE.
DEPHOSPHORYLATION OF TUBULIN                                                           Disclosure: The authors have declared no conflicts of interest.

Jessica J. Manson1, Kevin Mills2, David D’Cruz3, Moin Saleem4,                         Neutrophil apoptosis by disease type and Effect of serum on JSLE neutrophil apoptosis
David A. Isenberg1 and Anisur Rahman1
1                                                                                      Neutrophil Type                          Mean (þ/-SD) neutrophil apoptosis at 4 hours
  Centre for Rheumatology Research, University College London, London,




                                                                                                                                                                                       Downloaded from http://rheumatology.oxfordjournals.org by on August 24, 2010
United Kingdom, 2Biochemistry, Institute of Child Health, University College           JSLE                                                    66.4 (15.0)
                                                                                       SLE                                                     67.9 (15.1)
London, London, United Kingdom, 3Lupus Research Unit, St Thomas Hospital,              JIA                                                     37.2 (12.0)Ã
London, United Kingdom and 4Academic Renal Unit, University of Bristol,                Control                                                 43.0 (12.4)
Bristol, United Kingdom                                                                Serum Type                          Mean (þ/-SD)% apoptosis of JSLE neutrophils at 2 hours
                                                                                       JSLE                                                    44.3 (22.1)
Background: The glomerular podocyte plays a central role in preventing                 SLE                                                     31.7 (13.9)
proteinuria. Podocytes have a very characteristic structure, with major and minor      JIA                                                     22.7 (9.5)#
processes. Processes from adjacent cells interdigitate to form a near continuous       Control                                                 11.5 (9.5)#
layer around the glomerular basement membrane. The highly organized                    No serum                                                24.3 (12.4)#
cytoskeletal compositions of the processes are central to the functions of the         Ã
                                                                                        p < 0.05 JSLE & SLE compared to JIA neutrophils; p < 0.05 JSLE compared to JIA, controls and
cell. Phosphorylation of cytoskeletal proteins could affect these functions. The       no serum.
major processes contain bundles of microtubules composed of tubulin, while the
cytoskeleton of the minor processes is actin-based.Lupus nephritis (LN) is an
antibody mediated disease, causing proteinuria and podocyte abnormalities seen         321. TREATMENT ADHERENCE IN A COHORT OF SLE PATIENTS
on renal biopsy. The aim of this study was to investigate whether antibodies from
patients with LN have a direct effect on phosphorylation of proteins in cultured       Kiran K. Putchakayala1, C. Rao1, K. McElhone2 and Lee-Suan Teh2
                                                                                       1
human podocytes.                                                                         Department of Rheumatology, Victoria Hospital, Blackpool, United Kingdom
Methods: 16 patients with new onset, biopsy proven, LN were recruited from Lupus       and 2Department of Rheumatology, Royal Blackburn Hospital, Blackburn,
Clinics at University College London (UCL) and St Thomas’ Hospitals. Healthy           United Kingdom
controls were recruited from UCL staff. Plasma samples were either heat                Background: Adherence to medication is a major problem in chronic disease.
inactivated (HI), leaving immunoglobulin (Ig) intact, but destroying complement        Lack of adherence to treatment may cause organ specific damage in SLE and this
and cytokines, or passed through Protein G columns to extract IgG. After testing for   can lead to a higher cost benefit ratio in SLE management. The aim of this study
endotoxin, purified IgG was detoxified with polymyxin B columns if necessary. Fully    was to quantify the treatment adherence rates in a cohort of SLE patients. The
differentiated human podocytes were grown in medium containing either 15% HI           study also attempted to add to the knowledge about treatment adherence which
plasma or purified IgG at 100mcg/ml or 1.5mg/ml. Tyrosine phosphorylation of           may help us develop strategies to improve adherence rates.
podocyte proteins was assessed by Western blotting, and dominant protein bands         Methods: An anonymous self report postal questionnaire was sent to all patients
identified using MALDI/Electrospray qTOF mass spectrometry.                            who fulfilled the 1997 ACR criteria for SLE at two Rheumatology centres. The
Results: After 24 hours in culture there were differences in tyrosine phosphoryla-     questionnaire was in 3 sections: Section 1 explored adherence behaviour to various
tion of podocytes exposed to different samples. Compared to those exposed to           SLE treatments, Section 2 explored the use of alternative treatments and the
control plasma or control IgG there was significantly reduced phosphorylation in       patient’s perception of their health care professionals and Section 3 documented
podocytes exposed to plasma(p ¼ 0.0079)or to purified IgG from patients with LN        demographic data and co-morbidities.
(p ¼ 0.01) at 1.5mg/ml but not 100mcg/ml. This reduction was not seen after            Results: Of the 151 questionnaires sent 85 were returned (response rate of
exposure to plasma from 5 patients with non-renal lupus. There were three              56.3%). Mean age of patients was 53.16 yrs (SD 12.37) and mean disease duration
dominant tyrosine phosphorylated bands in podocyte extracts. The 50kDa band            was 11.14 yrs (SD 8.66). The majority of patients were white Caucasian (84.7%).
was subjected to in-gel enzymatic digestion. MS-TOF analysis of the peptides           Adherence to individual medication was variable (tabulated). Fifty seven patients
identified the protein as tubulin.                                                     (67%) also had a co-morbid condition needing other treatments. Patients were
Conclusions: IgG from patients with lupus nephritis causes a reduction in tyrosine     most adherent to conventional DMARD’s and least adherent to medication for bone
phosphorylation of podocyte proteins, including tubulin, which is the dominant         protection and sun blocks with adherence to steroids in between. Only 4.7% felt
cytoskeletal protein in podocyte major processes. These are new insights into          that they were not offered a good explanation for their treatments, but a larger
podocyte involvement in the immunopathogenesis of LN. Further podocyte studies         number (12.94%) felt that they were not adequately informed about their disease.
are required.                                                                          Thirty (35.29%) patients also took complementary treatments in addition to their
Disclosure: The authors have declared no conflicts of interest.                        regular treatments but only 3.6% were taking this as alternative to prescribed
                                                                                       medication.
                                                                                       Conclusions: These findings support those in a previous study in that
320. THE ROLE OF NEUTROPHIL APOPTOSIS IN JUVENILE                                      adherence to treatments depended on type of medication. Patients were likely
SYSTEMIC LUPUS ERYTHEMATOSUS                                                           to be adherent to immunosuppressive medication acting directly on the condition
Zoe L. McLaren1, Angela Midgley1, Robert J. Moots3, Steven W. Edwards2 and             in spite of substantial risk of side effects but were less adherent to the
Michael W. Beresford1                                                                  preventative treatments like bone protection and using sun blocks. Improving
1
  The Institute of Child Health (Royal Liverpool Children’s Hospital - Alder Hey,      communication between health professionals and patients may improve
Liverpool University, Liverpool, United Kingdom, 2Biological Sciences, Liverpool       adherence to these prophylactic agents. Further analysis is underway to determine
University, Liverpool, United Kingdom and 3Infection & Immunity, University            if any correlations exist between adherence behaviour and variables such as
                                                                                       patient’s beliefs in complementary therapy and knowledge of the underlying
Hospital Aintree, Liverpool University, Liverpool, United Kingdom
                                                                                       disease.
Background: Juvenile Systemic Lupus Erythematosus (JSLE) is the childhood              Disclosure: The authors have declared no conflicts of interest.
form of SLE, the archetypal autoimmune inflammatory condition. JSLE runs a more
severe course than SLE exhibiting a different pattern of organ involvement. Few
studies have investigated the immunopathology of JSLE. Abnormalities of                Medication                             Frequency of use(n)               Adherence rates(%)
neutrophil apoptosis may lead to the development of autoimmunity through               Oral Steroids                                   53                              86.79%
exposure of intracellular antigen in external blebs on the apoptotic cell surface.     Hydroxychloroquine                              58                              91.37%
In SLE there are increased apoptotic lymphocytes and neutrophils and defected          Azathioprine                                    20                            95%
phagocytic clearance of apoptotic cells which correlates with disease activity.        Methotrexate                                    12                           100%
                                                                                       Ca/VitD/Bisphosphonates                         46                              80.43%
Investigating the role of neutrophil apoptosis in JSLE may provide important
                                                                                       Aspirin                                         42                              90.47%
insights into this disease. Our hypothesis was that neutrophil apoptosis is abnormal   Sunblock                                        67                              83.58%
in JSLE.
Poster Viewing ll                                                                                                     Thursday 24 April 2008, 08.30–10.00 ii95

322. ANTI-DSDNA, ANTI-NUCLEOSOME AND ANTI-                                                 serological features of SLE. Long-term outcome appears to be favourable after
ALPHA-ACTININ ANTIBODIES IN THE PATHOGENESIS OF                                            intensive immunosuppressive treatment. This report highlights the need for
LUPUS NEPHRITIS                                                                            prospective multicentre studies to improve our knowledge and guidelines for the
                                                                                           treatment of this rare complication of lupus.
Alexander S. Ma1, Jessica Manson1, Lesely Mason1, David d’Cruz2,                           Disclosure: J.P.-R. has received a research grant from ISCIII Spanish Ministry of
David Isenberg1 and Anisur Rahman1                                                         Health and Consumer Affairs and a research grant from the Spanish Society of
1
  Centre for Rheumatology Research, Dvision of Medicine UCL, London,                       Rheumatology. D.I. has declared no conflicts of interest.
United Kingdom and 2Lupus Research Unit, Rayne Institute, St Thomas’
Hospital, London, United Kingdom
                                                                                           324. SEQUENCE MOTIFS IN HUMAN MONOCLONAL
Background: Anti-nuclear antibodies (ANA) are thought to contribute to the multi           ANTIPHOSPHOLIPID ANTIBODIES HAVE DIFFERENTIAL EFFECTS
organ pathology in SLE. Two theories may explain the autoantibody complex                  ON THE ACTIVATION OF CERTAIN SIGNALLING PATHWAYS THAT
deposition in kidneys of SLE patients suffering from lupus nephritis (LN). One             DO NOT ALWAYS MIRROR THEIR BINDING EFFECTS
theory involves the deposition of antibody-nucleosome complexes via ionic
attraction of the nucleosome for the glomerular basement membrane (GBM).                   A. Lambrianides1, C. Pericleous1, D. Latchman1, P. Chen2, D. Isenberg1,
Here, complexed nucleosomes act as a bridge between the GBM and anti-                      A. Rahman1 and I. Giles1
                                                                                           1
nucleosome antibodies. The other proposition is that ANA cross react with                    University College London, London, United Kingdom and 2University
-actinin, an essential component of glomerular podocyte cell junctions. This study        of California, Los Angeles, CA
intended to compare anti-nucleosome, anti--actinin and anti-dsDNA antibody
levels in the same patients with LN longitudinally to see which specificity correlated     Background: Up-regulation of signalling pathways and tissue factor (TF)
better with markers of renal disease.                                                      expression in monocytes is an important mechanism whereby aPL stimulate
Methods: A cohort of 16 patients with LN from University College and St. Thomas’           thrombosis in the antiphospholipid syndrome (APS). IS4, a monoclonal IgG aPL
Hospitals London was recruited for this study by Dr Jessica Manson. She took               derived from a patient with APS, is pathogenic in a murine model of thrombosis.




                                                                                                                                                                                  Downloaded from http://rheumatology.oxfordjournals.org by on August 24, 2010
serum and plasma samples at the time of their renal biopsy and up to eight further         Previously, we showed that surface-exposed Arg residues in IS4VH CDR3 are
samples over two years. Control samples were taken from UCL staff. I assessed              critical in determining binding to a range of anionic PL and 2GPI and influence the
levels of anti-dsDNA, anti-nucleosome and anti--actinin in each sample using the          ability of IS4 to promote thrombosis. We now describe the effects of changes in
Farrzyme assay, anti-nucleosome and anti--actinin ELISAs respectively.                    sequence and binding properties of IS4 on its ability to stimulate signalling
Indicators of the patients’ renal disease activity were acquired from their clinical       pathways in monocytes.
records and these data were compared with the autoantibody levels measured                 Methods: In expression vectors containing VH, VL and constant region cDNA, the
longitudinally.                                                                            distribution of Arg residues in complementarity determining regions (CDRs) of VH
Results: The mean levels of autoantibodies with dsDNA and nucleosome                       and VL sequences was altered by mutagenesis/VL exchange. Three 2a2 derived
specificity in patients were significantly increased (both p < 0.0001) compared to         VL (IS4, B3 - an antinucleosome antibody - and UK4, a 2GPI-independent aPL)
30 healthy controls. Anti--actinin levels in the patient cohort did not differ            were paired with native IS4VH. A variant of IS4VH, with different patterns of Arg in
significantly from the control group. Anti-dsDNA and anti-nucleosome levels                CDR3, was paired with IS4VL and B3VL. These plasmids were stably expressed in
correlated with each other (r 0.6, p 0.01) but not with anti--actinin. There was a        CHO cells, from which whole IgG was harvested and purified. All IgG was free of
positive correlation between urine protein/creatinine ratio and anti-dsDNA (p 0.04)        endotoxin (<0.06EU/ml) and used at 100g/ml in a human promonocytic (U937)
and anti-nucleosome (p 0.05) but not anti--actinin (p 0.40). There was a negative         cell line. Cell extracts were examined by immunoblot using total/phospho-specific
correlation between serum albumin and anti-dsDNA (p 0.032) and anti-nucleosome             antibodies to p38MAPK and NF-B p65 proteins. TF activity on monocytes treated
(p 0.027) but not anti--actinin (p 0.332). Each individual patient data was further       with maPL IgG was determined using a commercial assay.
analysed graphically to elucidated longitudinal trends, confirming that in most cases      Results: Substitution of IS4VL by B3VL reduced phosphorylation of p38MAPK but
anti-dsDNA and anti-nucleosome mirrored disease activity much more closely than            increased cardiolipin (CL) binding whilst substitution by UK4VL reduced CL binding
anti--actinin.                                                                            but increased phosphorylation of p38MAPK. We changed two Arg residues in
Conclusions: Anti-dsDNA and anti-nucleosome antibodies are found at consider-              IS4VHCDR3 to serine at positions 96 and 97. IgG containing this mutated VH
ably higher levels than anti--actinin antibodies in the majority of patients and these    paired with IS4VL did not bind CL at all, yet stimulated p38MAPK phosphorylation
levels correlate with their renal disease activity. Anti--actinin antibodies are a non-   in monocytes more strongly than native IS4. In contrast, IgG containing this mutant
specific finding in SLE nephritis patients but may be of relevance in the renal            VH paired with B3VL showed stronger CL binding than IS4 as well as increasing
pathogenesis of a minority of patients who have low nucleosome antibodies.                 p38MAPK phosphorylation. Similar results were observed with p65 phosphoryla-
Disclosure: The authors have declared no conflicts of interest.                            tion. The effects of two maPL IgG on monocyte TF activity have been tested. Native
                                                                                           IS4 caused a strong increase in monocyte TF activity. Interestingly, the non-CL-
                                                                                           binding variant of IS4 containing the substitution of two Arg residues in IS4VHCDR3
                                                                                           to serine at positions 96 and 97 also increased TF activity.
323. PSYCHOSIS DUE TO SYSTEMIC LUPUS ERYTHEMATOSUS:                                        Conclusions: Sequence changes in the maPL IS4 alter its ability to cause
CHARACTERISTICS AND LONG-TERM OUTCOME OF THIS RARE                                         phosphorylation of p38MAPK and NF-B p65 signalling pathways in human
MANIFESTATION OF THE DISEASE                                                               monocytes. These effects do not always correlate with ability to bind CL. These
Jose M. Pego-Reigosa1 and David A. Isenberg2                                               results highlight the non-linear relationship between aPL sequence, structure and
1
  Rheumatology, Hospital do Meixoeiro (Complexo Hospitalario Universitario de              function.
                                                                                           Disclosure: The authors have declared no conflicts of interest.
Vigo), Vigo, Spain and 2Rheumatology, Centre for Rheumatology Research,
University College London, London, United Kingdom
Background: There are very few data on psychosis due to systemic lupus                     325. LIVEDO RETICULARIS:A POTENTIAL CLINICAL MARKER FOR
erythematosus (SLE) reported after the publication of the 1999 American College of         VASCULOPATHY
Rheumatology (ACR) nomenclature for neuropsychiatric (NP) syndromes. The aim               David P. D’cruz, Tanikawa Akiko, Shirirsh R. Sangle, Munther A. Khamashta and
of our study is to determine the prevalence, characteristics and long-term outcome         Graham R. Hughes
of psychosis due to SLE defined according to those criteria.                               Lupus Research Unit, St Thomas’ Hospital, London, United Kingdom
Methods: All the patients who strictly fulfilled the ACR definition for psychosis due
to lupus were identified within the 485 patients of the University College London          Background: Objective: To evaluate the prevalence of abnormal pulse wave
Hospital lupus cohort followed up between January 1978 and June 2007 and                   velocity (PWV), pulse contour analysis (PCA) and abnormal ankle-brachial index
retrospectively evaluated.                                                                 (ABPI) in patients with livedo reticularis (livedo) and without livedo.
Results: Psychosis due to lupus was diagnosed in 10 (2.1%) patients. Lupus                 Methods: We enrolled 74 patients of which 41 had livedo: 15 primary antipho-
psychosis presented as the initial presentation of SLE in 60% of the patients and          spholipid syndrome (APS), 9 APS with systemic lupus erythematosus (lupus),
within the first year of the disease in 80% of the cases. Mild to moderate depression      17 with livedo (negative for aPL and SLE). Livedo was characterized by the 1st
was present in 90% of the psychotic patients. All the patients developed psychotic         author, a dermatologist. The ABPI was calculated using a 8MHz Doppler probe and
symptoms within the context of multisystemic activity of the disease. Most patients        sphygmomanometer in the arms and legs according to a consensus statement.
presented with cutaneous manifestations, with malar rash and skin vasculitis being         An ABPI<1.0 was considered to be abnormal. Arterial stiffness and endothelial
the most frequent (80 and 50%, respectively). Psychosis activity was associated            dysfunction were measured by the Pulse Trace device (PT2000, Micro Medical UK)
with several lupus biomarkers: 100% of the patients were ANA positive, 90% had             in fasting subjects using a standard methodology in a temperature controlled
raised anti-dsDNA antibody levels and 40% had low C3 levels. Antiphospholipid              environment. We measured carotid-femoral pulse wave velocity (PWVcf) by a
antibodies were observed only in 1 (10%) of the cases and anti ribosomal P                 4MHz Doppler probe and Stiffness Indices (SI) and Reflection Indices (RI) by a
proteins antibodies in 1 of the 4 patients tested. Sixty percent of our patients were      digital volume photo-plethysmography transducer Data on traditional cardiovas-
free of psychotic symptoms one year after the diagnosis and treatment of the               cular risk factors such as smoking, hypertension, hypercholesterolemia, obesity,
psychosis. Seventy percent of our patients showed complete resolution of                   andcorticosteroids was recorded. Fasting blood samples were collected for
psychotic symptoms after a mean follow-up of 155 months. Long lasting remissions           hs-CRP, homocysteine, cholesterol and aPL levels. Statistical analysis was with
were seen in all of those patients. Three of them presented with a second acute            Wilcoxen’s test between groups and Chi-square and Yates’s correction were used
psychotic flare up to 14 years after the diagnosis. Chronic mild psychotic symptoms        for categorical analysis.
were observed in 30% of our patients.                                                      Results: Median age of patients with livedo group was 46 (29 to 71) and non-livedo
Conclusions: Psychosis due to lupus is an uncommon event that usually occurs               group 45 (25 to 68) years. Mean PWVcf was significantly higher in the livedo group
early in the course of the disease and is associated with other clinical and               compred to those with non livedo (10.9 Æ 8.7 vs 8.57 Æ 2.64, p 0.04) In the livedo
ii96   Thursday 24 April 2008, 08.30–10.00                                                                                                                Poster Viewing ll

group there were 10/41 (24.4%) patients with abnormally elevated PWVcf values              Conclusions: Our findings indicate that engagement of CD40 on B cells empowers
compared to 2/33 (6%) in the non livedo group (2: p 0.03). MEAN abpi in the               a subset with regulatory capacity. Understanding how this subset functions in SLE
livedo group was significantly lower compared to the non livedo group                      may lead to improved treatment of patients with this disease.
(1.148 Æ 0.162 vs 1.232 Æ 0.11, p 0.01). There were 4/41 (9.81) abnormal ABPI              Disclosure: The authors have declared no conflicts of interest.
values in the livedo group compared to 0/33 (0%) in the non livedo group (p¼NS).
There was no correlation with the traditional risk factors.
Conclusions: In the livedo group PWV was significantly abnormal as compared to             328. MURINE LUPUS SUSCEPTIBILITY LOCUS SLE16: EPISTATIC
patients without livedo reticularis. Livedo reticularis may be an important marker         EFFECT OF A CHROMOSOME 3 LOCUS
of vasculopathy.
                                                                                           Francesco Carlucci1, Yasin Heidari1, Liliane Fossati-Jimack1, Terence H. Cook2
Disclosure: The authors have declared no conflicts of interest.
                                                                                           and Marina Botto1
                                                                                           1
                                                                                             Molecular Genetics and Rheumatology, Imperial College, London, United
                                                                                           Kingdom and 2Histopathology, Imperial College, London, United Kingdom
326. SIMVASTATIN REDUCES INFLAMMATION, DISEASE ACTIVITY,                                   Background: C57BL/6 and 129 are two murine strains widely used for the
AND IMPROVE ENDOTHELIAL FUNCTION IN SYSTEMIC LUPUS                                         generations of gene-targeting animals. Though both strains are not autoimmune,
ERYTHEMATOSUS                                                                              (C57BL/6x129)F2 hybrid mice develop a lupus-like disease. We recently described
Sergy V. Shevchuk                                                                          a C57BL/6 congenic line (named B6.129chr1b), carrying the Sle16 lupus
Rheumatology, Vinnytsya Medical University, Vinnytsya, Ukraine                             susceptibility locus of 129 origin, that spontaneously develops autoantibodies.
                                                                                           Previous genome-wide screen analyses for systemic lupus erythematosus (SLE)
Background: Premature coronary heart disease (CHD) is a major cause of                     susceptibility loci in (C57BL/6x129)F2 mice identified a 20cM interval on
morbidity and mortality in patients with systemic lupus erythematosus (SLE).               chromosome 3 of C57BL/6 origin linked to the production of lupus autoantibodies.
Statins reduce inflammation and disease activity in SLE patients, but whether this is      To investigate whether the C57BL/6 chromosome 3 locus was necessary for the




                                                                                                                                                                                       Downloaded from http://rheumatology.oxfordjournals.org by on August 24, 2010
due to pleiotropism or cholesterol lowering per se is unclear                              production of autoantibodies in the B6.129chr1b model, a C57BL/6 congenic line
Methods: Twenty one patients SLE (females), mean age 31 þ /-8 yrs, received                carrying a 129 chromosome 3 locus was generated. This chromosome 3 congenic
simvastatin 20 mg/day during 12 weeks. Twenty SLE control patients, mean age               strain (named B6.129chr3) was then crossed with the B6.129Chr1b line and the
34 þ /-7.5 yrs, not receiving simvastatin were followed during the same time period.       bicongenic mice (B6.129chr1bxchr3) were analysed.
Disease activity, blood pressure, brachial artery flow-mediated dilation (FMD), and        Methods: The B6.129chr1b, B6.129chr3 and B6.129chr1bxchr3 congenic animals
serum inflammatory markers were measured before and after treatment.                       were monitored up to 12 months with serial bleeding. Autoantibodies were
Results: Simvastatin significantly reduced total cholesterol (-6.66 þ /-5.35 mmol/l        measured by ELISA. The renal involvement was assessed by measuring
and control -5.49 þ /-5.68 mmol/l, respectively; p < 0.001), low-density lipoprotein       proteinuria. Flow cytometry analysis was used to characterize the spleen cells.
cholesterol (-4.39 þ /-3.15 mmol/l and control -3.57 þ /-3.63 mmol/l; p < 0.0001),         Results: The serological analysis at 3, 6, 9 and 12 months showed a gradual
and C-reactive protein (-18.0 þ /-13.8 mg/l and control -14.8 þ /-13.2 mg/l;               increase in the autoantibody levels (anti-nuclear, anti-ssDNA, anti-dsDNA, anti-
p < 0.001), tumor necrosis factor-alpha (TNF-alpha) (-228.3 þ /- 171.8 ng/l and            chromatin and anti-histone antibodies) only in the B6.129chr1b mice (p<0.001
control -212.5 þ /-199.2 ng/l; p < 0.001). Disease activity index SLEDAI (-23.5 þ /-       versus C57BL/6). More importantly in the B6.129chr1bxchr3 mice the autoantibody
19.6 and control -19.6 þ /-18.2; p < 0.001), and FMD (5.22 þ /-6.69% and 4.92 þ /-         titers were markedly reduced (B6.129chr1bxchr3 vs B6.129chr1b mice: p<0.001)
4.94%; p < 0.001).                                                                         and were not different from those detected in the C57BL/6 animals.
Conclusions: This study demonstrates that simvastatin reduce disease activity              The B6.129chr1bxchr3 congenics did not develop proteinuria and the histolo-
and inflammatory markers in patients with SLE. Therapy is also associated with             gical assessment of glomerulonephritis is in progress. FACS analysis of
improvement in endothelial function. This suggests that simvastatin has anti-              splenocytes showed increased B and T cell activation in the B6.129chr1b and
inflammatory effects and improves vascular function in SLE.                                B6.129chr1bxchr3 mice compared to the C57BL/6 mice.
Disclosure: The author has declared no conflicts of interest.                              Conclusions: These results highlight important epistatic interactions between
                                                                                           the Sle16 locus on chromosome 1 and a novel lupus locus on chromosome 3.
                                                                                           The locus on chromosome 3 was able to suppress the autoantibody production
                                                                                           induced by the Sle16 locus. Nevertheless the splenocytes of the B6.129chr1bxchr3
327. CD21HI CD23þ CD24HI REGULATORY B CELLS IN MRL/LPR                                     mice showed increased B and T cell activation compared to the C57BL/6 mice
MICE AND SLE PATIENTS                                                                      suggesting that some cellular alterations had occurred in these mice despite the
Paul A. Blair1, Karina A. Chavez-Rueda2, Sajjad Abbas1, Mark J. Schlomchik3,               lack of an autoimmune phenotype. These data indicate that gene(s) located in
David A. Isenberg1, Michael R. Ehrenstein1 and Claudia Mauri1                              the chromosome 3 locus are critical for maintaining B cell tolerance in the lupus-
1
  Medicine, University College London, London, United Kingdom, 2UIM en                     prone B6.129chr1b congenic strain. Future identification of these genes will help to
                                                                                           further elucidate the immunological processes underlying the pathogenesis of SLE
Immunologia, Hospital de Pediatria, Mexico City, Mexico and 3Department of
                                                                                           and provide novel therapeutic targets.
Laboratory Medicine, Yale University, New Haven, CT
                                                                                           Disclosure: The authors have declared no conflicts of interest.
Background: Different B cells subsets are key regulators of the choice between
tolerance and immunity. It has been proposed that B cells expressing CD19, CD24,
CD21 and CD1d maintain or restore tolerance via the release of IL-10, whilst other         329. ARTERIAL STIFFNESS AND CARDIOVASCULAR RISK
mature B cells drive autoreactive T cell differentiation, potentially via the production   FACTORS IN PATIENTS WITH ANTIPHOSPHOLIPID SYNDROME AND
of pro-inflammatory cytokines.                                                             RENAL ARTERY STENOSIS. A CROSS-SECTIONAL CONTROLLED
Methods: Mouse: B cells were magnetically isolated from the spleens of MRL/lpr             STUDY
mice and stimulated for 48hrs with anti-CD40. B cell subsets were defined by their         Marina Zakalka, Shirish R. Sangle, Munther A. Khamashta and David P. D’Cruz
expression of CD19,CD21,CD23,CD24 and, along with responder T cells, were                  Lupus Research Unit, The Rayne Institute St.Thomas’ Hospital, London,
purified by flow cytometry. For in vitro experiments, B cell subsets were incubated        United Kingdom
with responder T cells and cytokine production was measured by flow cytometry.
For in vivo experiments, 0.5x106B cells were transfered to syngeneic mice once a           Background: Vasculopathy may be a distinct clinical entity in the antiphospholipid
week for three weeks and disease progress was measured by proteinuria. Human:              syndrome (APS) that may lead to renal,coeliac and cerebral arterial stenosis. Our
Peripheral blood B cell subsets were defined by their expression of                        aim was to compare pulse wave velocity (PWVcf), pulse contour analysis (PCA),
CD19,CD24,CD38 and CD27. IL-10, TNF and IFN
 production were measured                     ankle brachial pressure indices (ABPI),Framingham risk scores and traditional risk
by flow cytometry following culture of PBMCs with either irradiated CD40L                  factors in patients with APS and renal artery stenosis (RAS), with two patient
expressing CHO cells or anti-CD3/CD28.                                                     groups and matched healthy controls.
Results: We have shown that ex vivo CD40 stimulation potentiates the                       Methods: We recruited 17 hypertensive patients (16 female) with APS (4 PAPS) and
suppressive capacity of MRL/lpr CD19þ,CD24high,CD21high, CD23high regula-                  RAS confirmed on imaging, 18 women with PAPS with thrombotic events, 18 women
tory B cells (Bregs) by increasing their production of IL-10. Functionally, Bregs          with SLE (aPL negative) without renal involvement and 15 healthy subjects. Data on
suppress Th1 inflammatory responses and generate regulatory T cells (Tr1) that             traditional risk factors were collected (diabetics were excluded). Arterial stiffness was
can inhibit responder T cell activation. Transfer of these T2-like Bregs to MRL-lpr/       measured by the Pulse Trace Device (PT2000, Micro Medical, UK), carotid-femoral
lpr mice inhibits autoantibody production, reduces lymphodenopathy, protenuria,            Pulse Wave Velocity (PWVcf) with a 4MHz Doppler probe and Stiffness Index
and gromerulo-nephritis leading to prolonged survival in an IL-10 dependent                (SIdvp) with a digital volume photo-plethysmography transducer. The ABPI was
manner. We have translated these findings to healthy individuals as well as to             calculated using an 8MHz Doppler probe according to a consensus statement.
patients with active SLE and identified an equivalent Breg subset in the peripheral        Results: The lnPWVcf was significantly increased in the APS and RAS group
blood (PB) that produces IL-10 in response to CD40 stimulation. In healthy controls        (mean PWVcf¼10.95Æ5.68m/s), compared to healthy controls (mean
this B cell subset displays a similar ‘‘transitional’’ phenotype (CD24high, CD38high,      PWVcf¼7.61Æ1.47m/s), (p¼0.006). The lnPWVcf was higher in the PAPS group
CD27-) and inhibitory function to its mouse counterpart. Depletion of this B cell          (mean PWVcf¼10.45Æ4.82m/s) compared to healthy controls (p¼0.054).
subset from healthy PB leads to a significant increase in TNF and IFN
 production         The lnSIdvp was significantly higher in patients with APS and RAS (mean
by responder T cells and abolition of IL-10 production. In contrast, CD24high,             SIdvp¼10.65Æ3.04m/s) compared to PAPS group (mean
CD38high, CD27- B cells from lupus patients appear to be refractory to CD40                   SIdvp¼8.70Æ3.16m/s), (p¼0.015) and to healthy controls (mean
engagement and produce significantly reduced amounts of IL-10 compared to                  SIdvp¼7.90Æ1.71m/s), (p¼0.055). The ABPI was significantly lower in APS plus
healthy controls, suggesting a compromised function of this subset of B cells in SLE       RAS patients compared to healthy controls (p¼0.031). Serum lntriglycerides were
patients.                                                                                  higher in the APS plus RAS group compared to PAPS patients, (p¼0.047) and to
Poster Viewing ll                                                                                                      Thursday 24 April 2008, 08.30–10.00 ii97

SLE, aPL negative patients (p¼0.003) and to healthy controls (p<0.001). PAPS            different CDR Arg were paired with native IS4VH. A variant of IS4VH, with mutated
patients had significantly higher triglycerides levels than healthy controls            Arg residues in CDR3, was paired with IS4VL and B3VL. VH/VL combinations were
(p¼0.048). Serum levels of HDL-cholesterol were significantly lower in the APS          expressed stably in CHO cells. Whole IgG was purified and confirmed to be
plus RAS patients compared to healthy controls (p¼0.020). The 10-yr predicted           endotoxin-free. Fresh human umbilical vein (HUV)EC were grown to confluence.
CHD and stroke risk scores were significantly higher in the APS plus RAS group          Purified monoclonal IgG at 200g/ml, LPS and PMA (positive controls) were added
compared to PAPS patients (p<0.001 and p¼0.004 respectively)and to SLE, aPL             to HUVEC for 4hours at 37oC. Supernatant was then removed and EMP in it
negative patients (p¼0.006 and p¼0.030 respectively) and to healthy controls            labelled with fluorochrome conjugated Annexin V (AnV) and a variety of monoclonal
(p<0.001 and p¼0.002 respectively).                                                     antibodies against EC surface markers. EMP phenotype and quantification were
Conclusions: PWVcf and SIdvp were elevated in all three patient groups                  assessed using 2-colour flow cytometry.
compared to healthy controls, but values between patient groups were similar.           Results: When IS4VL was replaced by B3VL both binding to cardiolipin (CL) and
The higher levels of triglycerides and the lower levels of HDL-cholesterol in APS       production of EMP from EC increased. When IS4VL was replaced by UK4VL there
and RAS patients may have contributed to vascular pathology in the renal arteries.      was a similar 2-3 fold upregulation of EMP production but a fall in binding to CL.
A possible link revealed between vascular stiffness measured by PWVcf and SIdvp         We mutated two Arg residues in IS4VHCDR3 to serine at positions 96 and 97.
and cardiovascular risk factors in APS patients.                                        These mutations in IS4VH abolished binding to CL, when the VH was paired with
Disclosure: The authors have declared no conflicts of interest.                         IS4VL but increased CL binding when it was paired with B3VL. However, these
                                                                                        mutations caused a 2-3 fold increase in EMP production on HUVEC exposed to
                                                                                        mutant VH paired with either of these VL compared to HUVEC exposed to native
330. POLYCLONAL IGG FROM PATIENTS WITH THE APS                                          IS4. All EMP were AnV high, and positive for VE-cadherin, endoglin, and for
STIMULATE THE PRODUCTION OF ENDOTHELIAL                                                 E-selectin and/or ICAM-1. There was no staining with P-selectin, VCAM-1 or TF.
MICROPARTICLES IN AN IN VITRO ASSAY                                                     Conclusions: We demonstrate for the first time that monoclonal aPL directly
                                                                                        activate EC and generate EMPs, and this is critically dependent on Arg residues at
Charis Pericleous, Lindsey A. Clarke, Paul Brogan, David Latchman,
                                                                                        specific locations. These functional effects, however, are not always predicted by
David Isenberg, Ian Giles and Anisur Rahman




                                                                                                                                                                                    Downloaded from http://rheumatology.oxfordjournals.org by on August 24, 2010
                                                                                        ability to bind CL.
University College London, London, United Kingdom
                                                                                        Disclosure: The authors have declared no conflicts of interest.
Background: The Antiphospholipid Syndrome (APS) is a systemic autoimmune
disease caused by the persistent presence of pathogenic antiphospholipid
antibodies (aPL). Numerous in vivo and in vitro studies have shown that aPL can         332. RATE AND FACTORS INFLUENCING PROGRESSION OF
activate endothelial cells (EC), predisposing patients towards a prothrombotic state.   ATHEROSCLEROSIS IN SLE
Furthermore, circulating endothelial microparticles (EMP), which are small vesicles     Sahena Haque1, Yasmeen Ahmad1, Joanne Shelmerdine2 and Ian N. Bruce1
derived from EC and thought to have procoagulant potential in disease, have been        1
                                                                                         ARC Epidemiology Unit, University of Manchester, Manchester, United
identified in APS patient sera. EMP are derived from cells which are activated or       Kingdom and 2The Kellgren Centre for Rheumatology, Manchester Royal
undergoing cell death, thus could be important markers of disease. This study           Infirmary, Manchester, United Kingdom
focuses on the ability of pathogenic aPL from patients with vascular thrombosis (VT)
and/or pregnancy morbidity (PM) to stimulate EMP production in an in vitro assay.       Background: Premature atherosclerosis is more prevalent in patients with SLE.
Methods: Human polyclonal IgG were purified from the sera of 6 female patients          While there have been a large number of cross-sectional studies, little is known about
with the APS using protein G beads. Equal numbers of samples from three different       factors that predict progression of atherosclerotic plaque in SLE patients. The aim of
groups were included in the study; those with VT alone (VTþ/PM-), PM alone              this study is to describe the rate of progression of carotid atherosclerotic plaque in
(VT-/PMþ) and both VT and PM (VTþ/PMþ). Polyclonal IgG was also purified                patients with SLE and to determine baseline factors that predict progression.
from 2 female healthy controls. Once isolated, samples were passed through an           Methods: White Caucasian female SLE patients were assessed in a prospective
endotoxin removing gel and confirmed to be endotoxin-free (<0.06EU/ml).                 observational study. Baseline cardiovascular risk factors, disease activity measure
    Human umbilical vein endothelial cells (HUVEC) were extracted from fresh            (SLEDAI) and SLICC damage score (SDI) were determined. B-mode ultrasono-
umbilical cords from healthy women donors and grown to confluence. Purified             graphy was performed to detect plaque of the common carotid and proximal
polyclonal IgG at 500g/ml, LPS and PMA (positive controls) were added to               internal and external carotid arteries at 2 time points at least 3 years apart.
individual wells for 4hours at 37oC. The supernatant was then removed and labeled       Results: 34 patients were assessed at baseline and at a mean of 5.5 years of
with a fluorochrome-conjugated monoclonal antibody recognizing Annexin V (AnV).         follow-up between scans. The mean (SD) age and disease duration at baseline
Monoclonal antibodies against EC markers E-selectin, P-selectin, VCAM-1,                were 50 (10) and 14 (10) years respectively. At baseline, 12 (35%) patients had
ICAM-1, VE-cadherin (CD144), endoglin (CD105) and tissue factor (TF) were               hypertension, 4 (12%) had hypercholesterolaemia, 8 (24%) had a family history of
also used to identify EMP. EMP phenotype and quantification were assessed using         coronary heart disease (CHD) and 15 (44%) were current or previous smokers. The
2-colour flow cytometry.                                                                median (IQR) baseline SLEDAI was 1 (0, 4) and SDI 1 (0, 2). Seventeen (50%)
Results: Polyclonal IgG from all 6 patients with the APS upregulated the formation      patients had progression in the number of carotid plaque of whom 11 developed
of EMP from EC (3- to 10-fold) compared to healthy controls. Upregulation was           new plaque having been plaque free at baseline. Thirteen (38%) patients remained
variable amongst patients, with no clear distinction between patient groups. All        plaque-free at the second time point. Four (12%) patients had plaque at baseline
EMP were AnV high, and stained positive for VE-cadherin and endoglin. EMP were          with no progression. Onset of new plaque during the follow-up period was
also positive for E-selectin and/or ICAM-1. There was no staining with P-selectin,      associated with older age, hypertension and hypercholesterolaemia, compared to
VCAM-1 and TF. We are now in the process of expanding these experiments by              those patients that remained plaque-free. Patients with new plaque were also more
increasing patient numbers in each group.                                               likely to have a lower SLEDAI and a higher SDI at baseline (Table 1).
Conclusions: To our knowledge, this is the first in vitro study showing that purified   Conclusions: Progression of carotid atherosclerosis was evident in half of patients
polyclonal IgG from patients with the APS, but not healthy controls, directly           with established SLE over a 5-year period of follow-up. Baseline factors contributing
stimulates the production of EMP in vitro. The pathophysiological significance and      to progression of atherosclerosis in this preliminary analysis include age, high
prothrombotic potential of EMP thus generated remains to be defined.                    cholesterol and hypertension. Lower disease activity and higher damage in those
Disclosure: The authors have declared no conflicts of interest.                         who progressed requires confirmation but suggests that mechanisms for suscept-
                                                                                        ibility to damage rather than inflammation per se may be more important in
                                                                                        atherogenesis in SLE.
331. SEQUENCE MOTIFS IN HUMAN MONOCLONAL                                                Disclosure: The authors have declared no conflicts of interest.
ANTIPHOSPHOLIPID ANTIBODIES HAVE DIFFERENTIAL EFFECTS
ON THE IN VITRO PRODUCTION OF ENDOTHELIAL
                                                                                        Table 1. Baseline risk factors and progression of carotid plaque
MICROPARTICLES THAT ARE NOT ALWAYS PREDICTED BY
THEIR BINDING PROPERTIES                                                                Baseline variable               Plaque-free N¼13       Onset of new plaque N¼11   P-value
                  1                   1               1                          1      Age (median & IQR of yrs)           46   (36, 51)              56   (49, 61)      0.005
Charis Pericleous , Lindsey A. Clarke , Paul Brogan , Anastasia Lambrianides ,          Hypertension (%)                     1   (7)                    5   (45)          0.033
Pojen Chen2, David Latchman1, David Isenberg1, Ian Giles1 and Anisur Rahman1            Hypercholesterolaemia (%)            0                          3   (27)          0.040
1
  University College London, London, United Kingdom and 2University of                  Family history of CHD (%)            3   (23)                   2   (27)          0.813
California, Los Angeles, CA                                                             Tobacco smoking (%)                  4   (31)                   4   (36)          0.772
                                                                                        SLEDAI !1 (%)                       10   (77)                   4   (36)          0.045
Background: Circulating endothelial microparticles (EMP), derived from activated        SDI !1 (%)                           5   (38)                   8   (73)          0.093
or apoptotic EC, have been identified in antiphospholipid syndrome (APS) patient
sera and may be important markers of prothrombotic potential. Previously, we
found that altering specific arginine (Arg) residues in the heavy chain (VH) of a       333. LUPUS PHENOTYPE ACCELERATES ATHEROSCLEROSIS IN
human pathogenic 2GPI-dependent aPL, IS4, and paired light chain (VL), had             A NOVEL MOUSE MODEL OF SLE
major effects on ability of the VH/VL combination to bind a range of clinically
relevant antigens. These binding properties did not always predict the effects of       Myles J. Lewis1, Talat H. Malik1, Liliane M. Fossati-Jimack1, Daniele Carassiti1,
these aPL upon EC activation in vivo and in vitro. We now describe the effects of       Terence H. Cook2, Dorian O. Haskard3 and Marina Botto1
                                                                                        1
these VH/VL combinations to stimulate EMP production from cultured EC.                    Molecular Genetics & Rheumatology Section, Imperial College, Hammersmith
Methods: The distribution of Arg residues in VH and VL complementarity                  Campus, London, United Kingdom, 2Histopathology Dept, Imperial College,
determining region (CDR) sequences were altered by VH/VL exchange or site               Hammersmith Campus, London, United Kingdom and 3BHF Cardiovascular
directed mutagenesis. Three 2a2 derived VL sequences (IS4, B3 - a human                 Medicine Unit, Imperial College, Hammersmith Campus, London, United
anti-DNA antibody and UK4 - a 2GPI-independent aPL) with >93% homology but             Kingdom
ii98     Thursday 24 April 2008, 08.30–10.00                                                                                                                      Poster Viewing ll

Background: Accelerated atherosclerosis has been identified as an important              Symptom                         % with symptoms               % with symptoms             P value
cause of morbidity and mortality in patients with systemic lupus erythematosus                                           ANA Positive by IIF          ANA Negative by IIF
(SLE). While epidemiological evidence for this is strong, the immunological              strokes                                    4.3                          1.4                0.53
mechanisms underlying the association are largely undetermined. Using a novel            Miscarriages                              11.3                         13.0                0.98
mouse model of lupus (B6.129chr1b) which develops high levels of lupus                   Deep vein thromboses                       5.7                          1.4                0.26
autoantibodies without significant renal disease, we aimed to investigate the            Pulmonary embolus                          2.8                          0.7                0.58
immunological links between atherosclerosis and SLE. Other mouse models of SLE           Dry or gritty eyes                        36.2                         39.0                0.97
are not suitable for this purpose due to confounding factors such as glomerulone-        Dry mouth                                 33.6                         28.1                0.80
phritis (GN) and vasculitis.
Methods: B6.129chr1b mice were crossed with low density-lipoprotein receptor
deficient mice (Ldlr-/-) to generate B6.129chr1b.Ldlr-/- mice, a novel mouse model
combining SLE and atherosclerosis.
Results: At 22 wks old on a low fat diet, B6.129chr1b.Ldlr-/- mice showed $3-fold
increase in whole aorta en face atherosclerotic lesion area compared to Ldlr-/-                                                    Vasculitis
controls (3.76Æ0.48% vs. 1.36Æ0.17%, meanÆSEM; P<0.0001) and a 68%
increase in aortic root lesions (2.95Æ0.37% vs. 1.76Æ0.64%; P¼0.02). On the high
fat diet, B6.129chr1b.Ldlr-/- mice showed a 79% increase in en face lesions
compared to Ldlr-/- mice (15.5Æ1.4% vs. 8.67Æ1.10%; P¼0.001) and a 43%                   335. ACUTE NEUROLOGICAL PRESENTATION OF TAKAYASU’S
increase at the aortic root (38.7Æ0.84% vs. 27.2Æ1.06%; P<0.0001), associated            ARTERITIS
with increased smooth muscle cell infiltration (P¼0.033). B6.129chr1b.Ldlr-/- mice       Laura R. Newton and David Carruthers
developed anti-chromatin antibodies at an earlier age than B6.129chr1b mice,             Rheumatology, City Hospital, Birmingham, United Kingdom
suggesting that the hyperlipidaemic environment accelerated autoantibody




                                                                                                                                                                                             Downloaded from http://rheumatology.oxfordjournals.org by on August 24, 2010
production. B6.129chr1b.Ldlr-/- mice on the low fat diet showed minimal GN               Background: Stroke in young patients has many aetiologies including vasculitis.
comparable to B6.129chr1b controls, but on the high fat diet B6.129chr1b.Ldlr-/-         Takayasu’s arteritis (TA) is a large vessel vasculitis which predominantly affects the
mice showed increased GN. However no mice developed significant proteinuria.             aortic arch and its large branches but diagnosis is typically late in the course of the
Conclusions: These results show that immunological dysfunction occurring early in        illness due to non-specific symptoms or an asymptomatic early phase of disease.
the pathogenesis of murine lupus substantially accelerated atherosclerosis. The          In contrast, many organ systems can be involved late in the disease, with 50% of
development of atherosclerosis in these mice also accelerated the development of         TA patients developing neurological manifestations. When the presenting feature
lupus both in terms of autoantibody production, but also in the development of GN on     of TA is an acute neurological ischaemic event, a delay in diagnosis can still occur.
the high fat diet. This implies that the two diseases are accelerating one another. In   This case series highlights important historical and clinical features that will assist in
human terms, this study suggests that patients with autoantibodies without organ         an early diagnosis of TA in patients presenting with stroke.
damage may still be at substantial risk of accelerated atherosclerosis. This new         Methods: Patients diagnosed with TA after presentation with acute neurological
mouse model will allow further elucidation of the immunological processes                conditions were identified from our register and their notes retrospectively
underlying accelerated atherogenesis in SLE, and is an important step towards            reviewed. Demographic details, clinical features at presentation, prodromal
identifying novel therapeutic targets for vascular disease in lupus patients.            symptoms and inflammatory markers were recorded.
Disclosure: The authors have declared no conflicts of interest.                          Results: Six patients (three male, three female) with a mean age of 32 years were
                                                                                         identified. Two patients were Asian and four Caucasian. Four patients presented
                                                                                         with stroke, one with a TIA and one with syncopal episodes. All patients had stroke
334. CLINICAL UTILITY OF ANA MEASURED BY ELISA COMPARED                                  confirmed (or ruled out) with CT þ/À MRI brain. History revealed that all six patients
WITH ANA MEASURED BY IMMUNOFLUORESCENCE                                                  had symptoms of vascular insufficiency prior to presentation: four had TIAs and
G. A. Maguire1, A. A. Ginawi2, J. Lee2, A. Lim2, G. Wood1, S. Houghton1,                 three had arm claudication. Three patients also had ‘prodromal’ symptoms of fevers
D. S. Kumararatne1 and J. H. Gaston2                                                     and headache. Four patients had at least one risk factor for ischaemic stroke, most
1
  Department of Clinical Immunology, Cambridge University Hospitals NHS                  commonly smoking. Examination in five patients demonstrated at least one
Foundation Trust, Cambridge, United Kingdom and 2Department of                           abnormal clinical feature at presentation (bruits or pulse loss) supporting a
Rheumatology, Cambridge University Hospitals NHS Foundation Trust,                       diagnosis of TA (table). Three patients had either a raised ESR, CRP or both. Two
Cambridge, United Kingdom                                                                patients had normal acute phase response. Vascular imaging confirming the
                                                                                         diagnosis of TA included angiography in all six patients (MRA in 4), and USS neck
Background: The measurement of anti nuclear antibodies (ANA) is important in             vessels in two patients.
the differential diagnosis of suspected connective tissue diseases. The most             Conclusions: TA is an important diagnosis to consider in young patients
commonly used method for measuring ANA is indirect immunofluorescence (IIF).             presenting with neurological disease, especially stroke. The admitting physician
The IIF assay is being replaced by ELISA assays which are easily automated and           must enquire specifically for prodromal or ischaemic symptoms and examine for
do not require as high a level of operator skill. To test whether the ELISA ANA          bruits, pulse loss and BP difference in the upper limbs to provide clues to an
missed significant disease that would have been identified by the IIF ANA, we            underlying large vessel arteritic disease process. In addition, this case series
undertook the present prospective study. We compared the frequencies of                  highlights the importance of considering TA even in male, non-Asian patients who
symptoms in patients who were negative by ELISA ANA but positive by IIF ANA              already have !1 risk factor for ischaemic stroke and have a normal acute phase
with those in patients who were negative in both assays.                                 response. Clinical suspicion allows appropriate investigations to confirm the
Methods: All 1239 patients attending the Rheumatology clinic over a 12 month             diagnosis, and early intervention to prevent further morbidity and mortality.
period for whom an ANA was requested were included in the study. ANA was                 Disclosure: The authors have declared no conflicts of interest.
measured by both IIF on HEp-2 cells (Binding Site) and ELISA (Phadia Varelisa
ReCombi ANA Screen assay). 169 (132 female, aged 52.8Æ14.7 [mean ÆSD]
                                                                                         Patient condition, clinical signs and blood test results
years, 37 male, aged 50.1Æ15.0 years) patients were positive for ANA by IIF but
negative by ELISA. Matched controls (132 females 52.8Æ14.7 years old and 39              Presenting Condition          Bruit          Pulse Loss      BP Diff          ESR        CRP
males 51.1Æ15.2 years old) were selected from patients who were negative by both         4 stroke 1                 4 patients        4 patients     4 patients    25 (15-44)   16 (<5-67)
assays. A questionnaire, including questions from established questionnaire for            TIA 1 syncope            (subclavian         (carotid
systemic lupus erythematosus screening, was sent to all patients. Responses from                                     or carotid)      or brachial)
the two groups were analysed by the Chi squared test.                                    (median and range shown).
Results: There were no statistically significant differences in the reported
symptoms between the two groups (Table).
Conclusions: Patients who are ANA positive by IIF but negative by ELISA do not           336. AUDIT OF THE INITIAL MANAGEMENT OF GIANT CELL
represent as significant clinical subset since they did not differ in their symptom      ARTERITIS - ON BEHALF OF THE ALL WALES RHEUMATOLOGY
profile from those who were ANA negative by both assays.                                 GROUP (AWRG)
Disclosure: The authors have declared no conflicts of interest.
                                                                                         Gwenan Huws, Ceril Rhys-Dillon and Nadine Perez
                                                                                         Rheumatology Department, Royal Glamorgan Hospital, Llantrisant,
Symptom                    % with symptoms           % with symptoms           P value   United Kingdom
                           ANA Positive by IIF      ANA Negative by IIF
                                                                                         Background: GCA is the commonest of all the vasculitidies with potentially serious
Hair loss                          9.9                      12.1                0.95     long term complications. It is also one of the most common indications for long term
Raynaud’s                         38.6                      39.9                1.00     steroids and is subject to wide variations in clinical practice, suggesting a need for
Pleurisy                          10.7                      16.2                0.60
Mouth ulcers                      17.1                      18.2                1.00
                                                                                         clear clinical guidelines. The BSR and BHPR recently published draft guidelines for
Sensitivity to sunlight           17.0                      17.0                1.00     the management of GCA(May 2007). This audit is based on the recommendations
proteinuria                       24.3                      20.4                0.89     and audit standards set out in those guidelines.
Malar rash                         7.8                      10.1                0.92     Methods: A tick-box audit form was created to assess the initial management of
Painful swollen joints            75.9                      80.4                0.83     GCA by Rheumatologists in Wales. The form was divided into 10 sections, focusing
Fatigue                           81.3                      83.1                0.98     on the following areas: 1.Baseline data, 2.Presenting symptoms, 3.Examination
Frequent fevers                    9.4                      11.7                0.94     findings, 4.Steroid treatment, 5.Investigations, 6.Temporal artery biopsy, 7.Bone
Severe headaches                  23.4                      24.7                1.00
                                                                                         protection, 8.Proton pump inhibitor, 9.Low dose aspirin, and 10.Patient education.
                                                                            Continued.

								
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